the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Monday, January 21, 2008

toughen up

during the old days of training, the prof believed in toughening us up. looking back i still wonder whether it was necessary.

there is a lot said these days on some blogs about the 80 hour work week. in those days we hadn't even heard of such a thing. there was no such thing as time off post call. any day of the week you had to be available for your patients. there was no such thing as handing a patient over to someone else because you were tired or upset or whatever. i remember being on call on friday night, working through the night. working through the next day to work off the leftovers and only getting home at about 9 the next night. then being on call the next day and night and doing a full day's theater list the day after on monday. after the list you operate the leftovers and the comebacks from the call. by tuesday you struggle to remember your name.

but i digress, as usual. this story comes from much later on in my training. i was the senior, the number one dog. i was in the toughest firm, the rounding off. after call, the prof would take us on academic rounds. as a junior i always struggled to stay awake during these rounds, having often only had one or two hours sleep the previous night, but somehow as the senior registrar in this particular firm the tension on the round was always enough to keep me wide awake.

without fail, on these rounds, the prof would tell us to take one patient back to theater for some or other reason. we used to bet about which one he'd chose. we were usually unpleasantly surprised. at a certain patient, usually towards the end of the rounds, the prof would look at me and with a wry smile say, 'you need to take this patient to theater.'

'yes prof.' i always replied and smiled back. in front of that prof it was important to show no weakness. he was like a pack of wild dogs. if he sensed fear he would tear you apart. he would then volunteer to join me if it happened before home time. this would never happen. by the time we booked the patient on the emergency list after the rounds, the list would be so full that we usually operated late at night.

this sort of behaviour is, of course, questionable. one wonders if it really was necessary to operate the patients. the answer is mostly yes, but not necessarily immediately. it wasn't so much about the patients but about training surgeons who would have the ability to put their own needs (even physiological needs) on hold if need be in order to be able to do what is needed for the patients, be they only future patients.i'm not presenting answers to these questions. i'm only stating things that happened.

however recently i have had the dubious pleasure of operating quite a number of patients with very complicated gallbladder disease. interestingly enough, although the surgeries were complex and challenging, at no stage was i even slightly phased. i realised this had a lot to do with many complicated gallbladders that i operated post call at the prof's beck and whim so many years ago.so one can't help wondering at the method in his madness.

10 comments:

I can recall those long days/nights. Don't have the answers regarding controlled hours, but do feel like I would have missed a lot with the restrictions they have now. Do wish I had read more then....Balance is a difficult thing.

I am in awe of your generation. Perhaps we newcomers will learn some of the same toughness, but only after we're out in private practice, and don't have a large group to share call with, or anyone counting the hours we work.

When does it get to the point that surgeons are driven into such a state of exhaustion that they become less effective? Or is there no other choice? I can think of a number of jobs where I wouldn't want a sleep deprived person in charge (pilot, bikini waxer) and a surgeon is definitely one of them!

bongi, i completely agree with you. many of the new generation bring the statements of fatigue being an issue. complain about low pay and high hours. everyone wants a "touchy feely" experience. "don't criticize me when i make a mistake ... it's not my fault, i was just covering ... i have to go because i am over hours... i have a hair appointment" (whinnying and pretending to cry)

truth be told, i learned the most during those stressful days in residency where i was pushed to do the next right thing. one of the problem i have with the 80 hour restriction is not decreasing the time and having rules, it is the mentality that it creates. surgeons are not shift workers. the residents always believe that "when i get into practice, i will be able to do this." i believe if you don't do it in practice, you not going to do it in the game.

and as cutonthedottedline alluded to, if you are in solo private practice, you may have to do it anyway without someone protecting you.

someone, yes. in the end surgery should be about the patient and service delivery. the newer generation seems to think it's about the poor surgeon.i also am not sure there is enough time to learn to do all the things you should be able to do with only 80 hours a week. the competition to operate must be fierce.having said this, there also needs to be balance. the old style training is also not ideal.

It's like serving in Vietnam. I wouldn't want to do it again, but I'm glad I did it. It taught me things. My training was like yours: exhausting, demanding, days on end without going home at all. As chief on trauma, it was two months straight. I could never do it again; I wouldn't have been the surgeon I was without it. For better or for worse, I think it's an undeniable fact that surgeons right out of training have neither the desire nor the stamina to work that hard (not everyone, of course.) It manifests itself in the number that seek alternatives after only a few years in practice.

A group of third year medical students recently joined our general surgery department for an elective. I was amazed at how child-like they all still were. After watching a two hour operation, they declared themselves exhausted, feet more tired and sore than they'd ever been. The students took themselves off for an extended lunch break and sat out off the next operation to rest. These kids will be the next generation of doctors. Sure, much happens between third and final years, they were yet to do their clinical blocks. But seriously!

Training in Pretoria has defiitely taught me that there is no such thing as sitting out because you are ill, or leaving at five for a late hairdressing appointment or booking a flight for the morning when you should be post-call.

My patients' wellfare come before my own needs. No question. And I believe that's the way it should be. I knew that surgery would be a hard life and I still chose it. Only thing is, we are still human, supremely toughened up humans, sure, but there should be some sense of respect for our humanity. Dedicating all your physical and mental strength to your patients should be appreciated. I think one should give your absolute best when you're on call, then do your post-intake hand-over in the morning and the colleague on call for that day should take over from there. Weekend ward rounds should be divided well so one doesn't end up being at work every weekend even when not on call. One has colleagues, we should work together. Honestly, when would it ever happen that a single surgeon is stuckon a desert island in a war zone and has to operate all the casualties day and night, alone? And that is what training in SA and esp at Pretoria university is like.

Marriages have fallen apart and children have grown up without knowing their parents because too much time had been spent taking care of other people's families and not your own.

Anaesthetists have a good way of dealing with hours (often frustrating to the surgeon though). They take over from each other; seniors would give juniors a break, assist on them grabbing a cup of coffee. They realise that tiredness leads to break in concentration, which in this job, leads to death.

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.